AB0223 ADHERENCE TO TREAT-TO-TARGET APPROACH IN A RHEUMATOID ARTHRITIS COHORT: RETROSPECTIVE ANALYSIS FROM 3 YEARS OF REAL-LIFE EXPERIENCE IN A REFRACTORY CLINIC
Authors: B. Maranini, E. Silvagni, V. Venturelli, A. Piovani, E. Zagnoni, M. Govoni
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> The European Alliance of Associations for Rheumatology (EULAR) advocates a "treat-to-target" (T2T) strategy for rheumatoid arthritis (RA) management, consisting in adjusting therapy if target is not achieved at 6 months. However, patients with moderate disease activity (MDA) currently constitute the most common RA patient subset in clinical practice, possibly leading to refractory RA, defined as resistance to multiple drugs with different mechanisms of action and persistence of physical symptoms and/or high disease activity (HDA). Real-life studies examining the impact of switching/swapping versus not switching/swapping therapies in RA active patients are still limited. <h3>Objectives</h3> To evaluate predictors of therapy switch/swap in a population of patients with refractory RA who already failed ≥ 1 biological/targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD), not reaching predefined target at 6-months after starting subsequent lines of DMARDs. <h3>Methods</h3> This single-center study retrospectively included 117 patients evaluated at our Clinic from 2019 to 2022. During subsequent 3- and 6-months T2T visits, disease activity through 28-joint disease activity score (DAS28), organ damage, treatment changes and composite disease activity indices were recorded. Chi square and Fisher's exact test was used for comparison of dichotomous variables and oneway analysis of variance (ANOVA) for continuous variables. Threshold of statistical significance was defined as a p-value &lt; 0.05. <h3>Results</h3> 66 patients (56.4%) did not achieve remission or low-disease activity target 6 months after starting b/tsDMARD; among them, 47/66 (71.2%) were in MDA, 11/66 (16.6%) in HDA and 8/66 (12.1%) were lost at follow up. 24/66 patients (36.4%) switched/swapped therapy at 6-months follow up. Longer disease duration correlated with treatment continuation (p=0.04). HDA at 6-months was a strong predictor of treatment change (p=0.009), as well as drug suspension for all reasons (e.g., safety issues, lack of therapeutic efficacy reported in medical records; p &lt; 0.001). Major results from ANOVA are summarized in Figure 1: Evaluator's Global Assessment (EGA) at 6-months significantly correlated with treatment switch (p=0.007), while patients taking drugs from more time tend to be switched less frequently (p=0.01). Remarkably, we did not find any correlation between the variations of DAS28, Global Health (GH), swollen joint count (SJC), tender joint count (TJC), Health Assessment Questionnaire (HAQ), Visual Analogue Scale (VAS) for Pain, steroid dependence. Similarly, baseline erosions, seropositivity, or number of prior DMARDs did not influence the outcome. <h3>Conclusion</h3> In our retrospective cohort study, drug switching seems not linked to a more severe disease. Examining disease activity indexes, neither baseline data nor PROs, but only 6-months EGA, appears statistically significant. While a number of explanations might be offered, including limitations of the current RA measurement tools, such as DAS28, and the limited sample size, our findings are concerning, suggesting that probably, in real-practice, a sort of physician "general impression" rather than objective findings of disease activity still guide therapeutic switching. <h3>Reference</h3> [1] van Vollenhoven R. Treat-to-target in rheumatoid arthritis - are we there yet? Nat Rev Rheumatol. 2019 Mar;15(3):180-186. doi: 10.1038/s41584-019-0170-5. PMID: 30700865. <h3>Acknowledgements:</h3> NIL. <h3>Disclosure of Interests</h3> None Declared.